Very little is known about the pathways that link broad environmental factors to health behaviors, and then to cardiometabolic risk across the lifecycle, taking into account the complex mediation and moderation by diet, activity, and weight over time. The primary reasons for this lack of understanding are: 1) insufficient high- quality, longitudinal exposure data; 2) lack of data in populations undergoing rapid changes in environments and outcomes, with enough variability to observe changes; and 3) insufficient use of complex statistical models to allow examination of each piece of the time-dependent, complex system. The China Health and Nutrition Survey (CHNS), an NIH-funded study of more than 11,000 individuals followed over 20 years, provides high- quality longitudinal data and captures the dramatic emergence of obesity, hypertension, insulin resistance, type 2 diabetes and cardiovascular disease in parallel with urbanization during the past two decades. The proposed study takes advantage of these unique data to examine patterns of change in communities characterized by different levels of urbanization over time. Using sophisticated structural models we propose to examine the complex pathways through which community-, household- and individual-level factors affect diet and physical activity, then the rate, degree and timing of weight gain and ultimately, cardiometabolic risk across the lifecycle. China is uniquely positioned to answer these questions given its high prevalence of cardiometabolic risk factors at relatively low BMI and at younger ages, and the relatively higher abdominal obesity and high rates of insulin resistance in Asians. We capitalize on a vast array of longitudinal anthropometry, blood pressure and detailed behavioral, socioeconomic and environmental information as well as newly collected fasting blood samples for cardiometabolic biomarkers. Our objectives include: 1) developing a longitudinal, structural model to investigate how community, household and individual factors influence: (a) energy-related diet and physical activity behaviors, (b) weight and waist circumference and (c) blood pressure over 20 years; and 2) extend the same multilevel, pathway-based analyses (Aims 1a-1c) to markers of dyslipidemia, insulin resistance and sensitivity, and inflammation. The proposed research will inform prevention and treatment strategies to optimize the effectiveness of cardiometabolic risk reduction efforts, with greater understanding of the role of broader societal, economic and environmental contexts in populations at risk. PUBLIC HEALTH RELEVANCE: China is a rapidly modernizing country experiencing substantial burden in hypertension, diabetes and cardiometabolic risk, providing a unique model for examining development of risk. The objective of the proposed research is to understand the multiple pathways from environment, behavior and biology to cardiometabolic risk across the lifecycle in order to inform efforts to mitigate early development of disease risk across the globe.